Small health changes are good!

In the early theoretical analysis for my thesis, I came across two key papers: the first is an economic analysis of lifestyle interventions by general practitioners for people with diabetes by Rob Carter and colleagues back in 1997 (Dalton 1997). The second is also an economic analysis, investigating treatment and prevention strategies for obesity commissioned and published by the OECD (Sassi 2009; 2010).

When I say "economic analysis" it means [loosely/broadly] a series of rational hypotheticals to understand what is happening, why, and with what consequences. How it works is you create an evidence-based hypothetical model of a service, or intervention, from the literature, and then you put into the model what you know for sure (from the evidence), then make evidence-informed rationalised assumptions to fill in the gaps to work out stuff like cost-effectiveness. Think of it as a mathematical sequence of events drawn from the literature: if I do this to x, what happens to y?

Or just take this message: economics is a science of decision-making; and health economics is a science of decision-making about health.

This kind of health economic modelling (econometrics) forms one part of the decision-making about health services. You can imagine if you were making decisions about funding one health service over another, the cost effectiveness of a service would be an important part of making that decision. Not the only part of course, and not always the most heavily weighted part of making decisions.

Imagine what happened if we only ever funded the most cost-effective services? What do you think such decision-making would do to equity and justice? This does not mean we blindly fund all health services, or that there should be a blanket fund to anything health. We are all accountable for our use of the scarce resources available, and to do our best to make informed judgements about what we do.

A special note for my dietitian colleagues: my work is about capturing what we do so we can report efficiency and effectiveness. If you feel anxious about this kind of reporting….read related blogs 1 and 2….and know I am here to hold hands as we get on top of this data stuff. Promise. Data will in fact raise and support our professional autonomy and credibility.

Right. Back to the “evidence small changes are good thing”. Carter’s work (Dalton 1997), and more recent, his teaming up with Boyd Swinburn, and Marg Moodie in the ACE series of economic modelling for obesity, consistently supports the early findings:

“…lifestyle changes that can be sustained over the longer period are better than dramatic changes that cannot be sustained”

Of course the body of work on the econometrics of prevention and treatment strategies for overweight and obesity are more detailed than this sweeping one-liner I have pulled out of the results. But having read across the literature, I can tell you there is something in the “small changes”. And in fact, Sassi’s work reports:

“The dietitian-GP partnership is potentially the most cost-effective long term strategy to halt and reverse obesity”

I hypothesised the dietitian-GP partnership came out on top is because of the intricacy of making
decisions about food: changing the know what to know how.  Dietitians are trained specifically to support behaviour change that is so completely individual driven, public health campaigns for prevention are not sufficient in the day to day challenges of “sticking to the two and five”.

Wait. Before you start tweeting “see small sustainable changes are better” remember how we practice to evidence, and we translate this evidence as suited to the person in front of us? What that means in this scenario is, the evidence suggests, “overall, small changes are good, and are likely cost-effective”. But we know as practitioners some people really do respond better to a dramatic change first, and then need the dietetic support to keep to it – what is best for this person at this time in this clinic with this dietitian? What is the client in front of me really telling me? Of all the options I know of to support this person to achieve their health goals, which ones will I pitch to this person as the MOST SUITABLE option at this time?

Epilogue
Evidence-based practice means the health professional brings all they know about all the evidence, and translates this to present the best option/s for what works for this person at this time. Data from that decision-making provides evidence of what works why/why not to inform clinical decision-making.

Tips du jour:
1. Small changes make a positive contribution to Australia’s health
2. Health economics is one part of the information needed to make decisions about health services

3. Dietitians can make a measurable impact on Australia's health statistics

Other blogs by me

[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month 
The story of dietitians for professional integrity
What is professional integrity?

[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together

Evidence-based confessions of a dietitian

Dietitians: as effective as the evidence from clinical trials

Evidence small health changes are good

[Other stuff]

Time for a health bottom line
The power of consumers
NO juice for Australian babies
Contributing to understanding dietetic practice
Maximising online survey participation
An evidence-based food future?

References

Organisation for Economic Co-operation and Development (OECD) Publications available at www.oecd.org 

Sassi F, Cecchini M, Lauer J, Chisholm D.  Improving lifestyles tackling obesity: the health and economic impact of prevention strategies.  OECD Health Working Papers No. 48

and

Sassi F.  Obesity and the economics of prevention: Fit not fat.  OECD 2010

Dalton A, Carter R, Dunt D.  The cost-effectiveness of GP-led beahavioural change involving weight reduction: implications for the prevention of diabetes.  Centre for Health Program Evaluation, Monash University.  Working Paper No. 65 1997

Dietitians: as effective as clinical trials

Yesterday I started writing this article here (the one you are reading now) but ended up writing about some other stuff as a prelude: Confessions of a dietitian.  Today I am going to add to the discussion on the effectiveness of dietitians. 

Put the trolleys in your mind (from yesterdays post, or here).  One trolley illustrates what the evidence says should be in our trolley to be healthy (proportions of fruit, veg, lean meat, dairy, extras etc), the other trolley is what Australians actually put in their trolley.  There is clearly a gap (and a rather big one) between what the evidence says to eat - ADG trolley, and what we do eat - Real-life trolley.  The evidence-based (ADG) healthy trolley is what dietitians are trained to support people to achieve.  But when you look at the real-life trolley, where would you start in trying to get people to achieve the healthy trolley? 

Here is an excerpt from an early version of my thesis' abstract:

A problem for dietitians is that there is an expectation their service will achieve the evidence-based health benchmarks of a healthy body weight (BMI<25kg/m2), meet fruit and vegetable intake targets, as well as exercise recommendations.  The expectation of a dietetic service exists despite the scientific evidence that few or no interventions achieve such health targets (Franz 2007; Cochrane 2010).

The central tenet of this thesis is that it is likely dietitians do facilitate significant and measurable improvements to an individual’s health, even where the improvements achieved fall well short of the health benchmarks.  There is evidence the small health gains that are achieved may be clinically significant, and even cost-effective (Dalton 1997; Sassi 2009).

And then I go on in the abstract and introduction to talk about the problem my thesis is investigating which is about data: collecting and reporting data from practice.  Sure, I’ve simplified “the problem” for this blog, and also, so there is some material left to put in the final thesis *ahem*.  But whenever I have presented this work to dietitians, there is a real sense of anxiety about reporting data from practice.  This anxiety is because dietitians know when it comes to achieving health improvements, especially weight – it is HARD, and outcomes may not present as “effective” because the improvements are small, if any. 

The first point to make is: if we continue to not collect and report data, we continue to keep doing what we are doing (and hope no one asks what we are doing or notices our existence).  If we collect, report and understand that data, we can start to build a practice-generated evidence-base about what we do with this patient at this time in this clinic with this dietitian.  And we can then do better (see hypothesis).  To me, this IS evidence based practice AND translational research.  BAM.  Winning. 

I’ve tweeted this catch phrase previously: “no data = no problems.  but no solutions”

Not sure who first said it, but I took it from Chris Bain’s presentation we did together on a Vic State job (back in 2009).  Thanks Chris, I've changed your quote a bit, Voevodin-style….where are you by the way?

The second point is: halting further weight gain is an important outcome, and a contribution to Australia's health statistics.  Before doing this research, I was unconvinced "halting is good too" - but now, I am convinced it really is good.  Evidence coming.  I know, I am promising a lot.  

In the first few months of my thesis, I was exploring effectiveness of dietitians.  Published studies from practice was sparse as expected (given we aren’t routinely collecting data yet), sure there were some RCTs looking at dietetic services versus other health professional’s services, while other studies compared one diet over another, but none stood out as THE intervention for weight management.  No real surprise there either because the diet that works is the one you can stick to (Thomas 2008). 

My work was not intended to find THE weight loss strategy and then implement that system across dietetic services.  My work is to be a step toward developing a system to record and report whatever it is that dietitian does with that patient at that time, and have that data reported back to the dietitian in a way that automatically generates useful data to make clinical decisions: what works, why, and when to change/add/adjust. 

There are many strategies to support people to achieve their health goals.  Dietitians are trained to know all approaches, to critically assimilate the information, and then translate that information for the person in front of them. We simply want an efficient system to capture what is done in the iterative exchange of information during a consultation.

A system that generates the evidence from practice is also a [critical] reflective practice tool.  The “evidence” presented to the dietitian supports a “putting aside” of their own personal philosophical approach that may be lurking and inadvertently influencing practice (sure, I’m guilty).  But also allows a bravery to step outside our own attitudes, beliefs, and behaviour, because dietitians will now have in front of them accurate, reliable, meaningful data on which to make the next critical decision. 

Epilogue

There is more to say about effectiveness of dietitians - in particular to highlight points from Dalton 1997 and Sassi 2009, and explain some economic modelling of health services. That to come (probably next week).

PS. The data that went to build the trolleys was an analysis I did in 2010 using a previous paper we'd published (Kettings 2009) and then data from the ABS (2008) on household spending. Just so you know it's not made up....details will be in thesis or a later publication.

Tips du jour:

1. Embrace data, lets use it to our advantage

2. Practice-generated evidence is the new black lets be the first to do it

Other blogs by me

[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month 
The story of dietitians for professional integrity
What is professional integrity?

[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together

Evidence-based confessions of a dietitian

Dietitians: as effective as the evidence from clinical trials

Evidence small health changes are good

[Other stuff]

Time for a health bottom line
The power of consumers
NO juice for Australian babies
Contributing to understanding dietetic practice
Maximising online survey participation
An evidence-based food future?

References

Australian Bureau of Statistics (ABS). All data sourced from the ABS was sourced online from www.abs.gov.au The data used in the trolley analysis is from 2008: household spending. This data was also reported in Australia's Food & Nutrition by the AIHW 2012. 

Cochrane Collaboration. Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese adults (Review) The Cochrane Library Issue 12, 2010 (see also Cochrane Collaboration. Long term non-pharmacological weight loss interventions for adults with type 2 diabetes mellitus The Cochrane Library Issue 1, 2009; or any other review of weight loss interventions on Cochrane).

Dalton A, Carter R, Dunt D.  The cost-effectiveness of GP-led behavioural change involving weight reduction: implications for the prevention of diabetes.  Centre for Health Program Evaluation, Monash University Working Paper 65.  

Franz MJ, JJ VanWormer, AL Crain, JL Boucher, T Histon, W Caplan, JD Bowman and NP Pronk. Weight-loss outcomes: systematic review and meta-analysis of weight loss clinical trials with a minimum of 1-year follow-up. JADA 2007 107:1755-1767 

Kettings CM, AJ Sinclair and M Voevodin. A healthy diet consistent with Australian health recommendations is too expensive for welfare-dependent families Australian and New Zealand Journal of Public Health 2009; 33(6): 566-572

Sassi, F. et al. (2009), “Improving Lifestyles, Tackling Obesity: The Health and Economic Impact of Prevention Strategies”, OECD Health Working Papers, No. 48, OECD Publishing.
http://dx.doi.org/10.1787/220087432153

Thomas S, Hyde J, Karunaratne A, Kausman R, Komesaroff PA.  "They all work...when you stick to them" A qualitative investigation of dieting, weight loss, and physical exercise, in obese individuals.  Nutrition Journal 2008; 7:34

Confessions of a dietitian

I am a dietitian, I have been a dietitian for about 16 years.  However, I have not done a one-on-one consultation with a client for probably eight years or more.  So in terms of what "dietitians do", well, I don't do that.  And I don't do that stuff because it is HARD.  There.  I said it.  It IS really hard supporting people to achieve their health goals.  And after years of research, observation, and sure, a bit of real-life practice, it has come down to this: it is hard because no matter what the dietitian does with each person during that consultation, it is that person, that individual, that then has to go out and navigate their way to making decisions about food three, four, even five times a day, and stick to an agreed "food prescription".  I'll explain further...

Dietitians are a counselling-based profession.  This means their role is as teacher-supporter-behavioural interventionist, but the actual work (the hardest bit) is up to the individual.  Compare this for example with a physiotherapist, a physical-based profession, where in the 15 or 20 minute consultation the "problem" can be alleviated.  The work is "done" on the spot, and the person exits with a clear gain in physical health.  Similarly, a doctor will write a prescription, you take that prescription, head to the pharmacy, decision-making is limited to which pharmacy (usually the closest) and then whether you choose a "cheaper brand" of the specific medicine.  Sure, you have to take the medicine....but how hard is that?  Rhetorical.  This is not a test.

I expect any dietitian reading this is hoping I clarify two things I've written in that opening paragraph.  Lets sort these out first so we can clear our heads for the real message.

1. What "dietitians do"

Dietitians do lots of things.  Heaps.  One-on-one consultations is one service that is simply "classically" representative of our profession.  Given Australia's chronic health statistics and projections for getting worse, one-on-one food and behaviour counselling is, and probably should be, the main service people see in the community as representative of the profession of dietetics.  But sure, we do lots of other stuff...research, policy, legislation....highly trained, smart, funny etc...

2. "Food prescription"

Writing out a "food prescription" for a client is a strategy, one strategy of many, that may be what the person in front of us needs at a particular time in their health journey.  Like many professions, dietitians don't want to be labelled or boxed into terms like "food nazi" or giving a "prescriptive diet".  But in fact, thinking about our service in these terms is what led me to draw parallels between what we (dietitians) do, and what other professions, like doctors and physios, do.  So, food is a dietitians intervention, our medicine.

When someone is not at their healthiest, making healthier food choices can help to alleviate or manage the problem: a dietitian "prescribes" foods that will make the person healthy.  We give a "food prescription" and then that person has to go out and get those foods and "take" the medicine prescribed.  Sounds easy, but, compared with the [two] decisions for getting a prescription (i.e which pharmacy and which brand of medicine), making decisions about food are far more challenging.  There is so much noise in the process from knowing what to eat, and actually eating it.  In every moment a decision is made about food, the process is a series of trade-offs influenced by many things, the price of food is just one of these.  There is the HARD bit, consistently sticking to the prescribed foods when the path to anything except the prescribed foods is more appealing.

What do we know for sure? Australian's are in the worst shape ever.  You know the stats: just over two in three Australian adults are above a healthy weight; ranked in the worlds "worst third" for body weight; diabetes set to increase and has some pretty awful associated health problems (AIHW 2012; Baker IDI 2012).  Dietitians, the experts in what to eat to be healthy, are well positioned to make a significant contribution to halting and reversing these health statistics.

Right. Here is me, one of these experts, trained to know and subscribe to the scientific evidence of what to eat to be healthy: eat two fruit, five veg, drink water (no other drinks), have a body mass index (BMI) at or below 25kg/m2, and do 60 minutes of moderate exercise every day.  The only one of these health benchmarks I meet is the BMI *yay genetics*!  Here is what bothered me when I was doing one-on-one consultations: if I can't achieve the health benchmarks, what chance do others have?  I could see my own inability to achieve what I should influenced what I did with clients. If they said "I don't have breakfast", I'd say "yeah neither do I".  If they said "gosh its too hot to exercise" I'd say "yeah I KNOW! It's outrageous".....or similar.  So I stopped doing, took a step back, and started questioning.

I became my own personal experiment: what is it about my decisions that divert me from the evidence?  This series of self-critique was the start of my work on the cost of healthy eating, the economics of decision-making to prioritise healthy eating, and a series of short vignettes on eating economics (to go into my thesis). And of course, the trolleys!  I've written about these preliminary ideas previously on my website (remember websites?) - but not in a blog....

It is this questioning of my own evidence-based prescription that brought me to my PhD - Can dietitians turn around the obesity epidemic? I really did wonder. And given how far Australians are from healthy eating (note the trolleys), is it reasonable to expect we CAN turn this around?  I believe we can, and there is evidence to support my belief.  It's coming....promise.


Epilogue
I know about stuff and I still struggle to eat to the evidence - but doing this research has allowed a "story" on decision-making about food that will contribute to what we know about the HARD bits, so we can be more effective.

What's that? Yes my eating is better thanks for asking.  I'm at one fruit, maybe four veg, and erm...one dairy.  Twenty minutes of intentional exercise a day....is it my fault I'm a fast runner?  And some incidental exercise - yes I take my housework seriously.

Tips du jour:
Erm....

Other blogs by me

[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month 
The story of dietitians for professional integrity
What is professional integrity?

[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together

Evidence-based confessions of a dietitian

Dietitians: as effective as the evidence from clinical trials

Evidence small health changes are good

[Other stuff]

Time for a health bottom line
The power of consumers
NO juice for Australian babies
Contributing to understanding dietetic practice
Maximising online survey participation
An evidence-based food future?

References
Australian Institute of Health and Welfare (AIHW). Australia’s health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra: AIHW  Available online at www.aihw.gov.au/publication

Australian Institute of Health and Welfare (AIHW). Australia’s food & nutrition 2012. Cat. no. PHE 163. Canberra: AIHWAustralia's Food & Nutrition  Available online at www.aihw.gov.au/publication

Baker IDI.  Diabetes: the silent pandemic and it's impact on Australia 2012  Available online at www.diabetesaustralia.com.au 

National Health & Medical Research Council (NHMRC).  Australian Dietary Guidelines 2013.  Canberra NHMRC  Available online at www.nhmrc.gov.au   Note the analysis for the "trolleys" were based on the earlier Australian Dietary Guidelines 2003, which are now superseded by the 2013 version.  However, the 2013 revision would make little change to the "healthy spend" trolley.